They are exposed to an array of pharmacologic interventions including opioids that not only lack evidence, but may also be harmful. This paper presents a novel treatment guideline that highlights the identification and diagnosis of CHS and summarizes treatment strategies aimed at resolution of symptoms, avoidance of unnecessary opioids, and ensuring patient safety.
This article describes one method, prescription drug monitoring programs (PDMP), through the lens of how to optimize use for emergency departments (ED). EDs have rapidly become a central location to combat opioid abuse and drug diversion. PDMPs can provide emergency physicians with comprehensive prescribing information to improve clinical decisions around opioids.
To date, there have been limited studies on the effect of default tablet quantities as part of emergency department (ED) electronic order entry. Our goal was to evaluate opioid prescribing patterns before and after the removal of a default quantity of 20 tablets from ED electronic order entry.
This was a retrospective, observational, cohort study of ED patients presenting for acute alcohol intoxication from 2012 to 2016. The study hospital is a county ED with an annual volume of 100,000 visits and 7,000 visits for alcohol intoxication.
Despite treatment guidelines suggesting alternatives, as well as evidence of a lack of benefit and evidence of poor long-term outcomes, opioid analgesics are commonly prescribed for back pain from the emergency department (ED). Variability in opioid prescribing suggests a lack of consensus and an opportunity to standardize and improve care. We evaluated the variation in attending emergency physician (EP) opioid prescribing for patients with uncomplicated, low acuity back pain (LABP).
Alcohol use disorders (AUD) place a significant burden on individuals and society. The emergency department (ED) offers a unique opportunity to address AUD with brief screening tools and early intervention. We undertook a systematic review of the effectiveness of ED brief interventions for patients identified through screening who are at risk for AUD, and the effectiveness of these interventions at reducing alcohol intake and preventing alcohol-related injuries.
Violence against healthcare workers in the medical setting is common and associated with both physical and psychological adversity. The objective of this study was to identify features associated with assailants to allow early identification of patients at risk for committing an assault in the healthcare setting.
Little is known about the use of involuntary psychiatric holds in preadolescent children. The primary objective was to characterize patients under the age of 10 years on involuntary psychiatric holds. We collected demographic data including age, gender, ethnicity and details about living situation, child protective services involvement and prior mental health treatment, as well as ED disposition.
Our goal was to describe the pattern and identify risk factors of early-return ED visits or inpatient admissions following an index mental health and substance abuse (MHSA)-related ED visit in the United States.
The U.S. opioid epidemic has highlighted the need to identify patients at risk of opioid abuse and overdose. We initiated a novel emergency department- (ED) based interventional protocol to transition our superuser patients from the ED to an outpatient chronic pain program. The objective was to evaluate the protocol’s effect on superusers’ annual ED visits.
The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs.
Effective strategies for managing acute behavioural disturbances (ABDs) within emergency departments (EDs) are needed given their rising occurrence and negative impact on safety, psychological wellbeing, and staff turnover. Our objective was to systematically review the efficacy of strategies for ABD management within EDs that involved changes to environment, architecture, policy and practice.
Author Affiliation Eric L. Anderson, MD University of Maryland, Department of Psychiatry, College Park, Maryland Kimberly Nordstrom, MD, JD University of Colorado School of Medicine, Department of Psychiatry, Aurora, Colorado; Denver Health Medical Center, Emergency Psychiatry, Denver, Colorado Michael P. Wilson, MD, PhD Department of Emergency Medicine Behavioral Emergencies Research lab, University of Arkansas for […]
Case reports and poison center data have demonstrated that the second-generation antipsychotic quetiapine is being obtained and used for recreational abuse. The purpose of this study was to describe the relative rates of single-substance abuse for different atypical antipsychotics and compare their demographic and clinical features.
In the United States, the number of patients presenting to the emergency department (ED) for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial.
An increasing number of behavioral health (BH) patients are presenting to the emergency department (ED) while BH resources continue to decline. This situation-may lead to more external transfers to find care.
Our study sought to examine the opioid analgesic (OA) prescribing decisions of emergency department (ED) providers who have themselves used OA therapeutically and those who have not. A second objective was to determine if OA prescribing decisions would differ based on the patient’s relationship to the provider.
The Peregrinating Psychiatric Patient in the Emergency Department
Scott Simpson, MD, MPH et al.
Many emergency department (ED) psychiatric patients present after traveling. Although such travel, or peregrination, has long been associated with factitious disorder, other diagnoses are more common among travelers, including psychotic disorders, personality disorders, and substance abuse. Travelers’ intense psychopathology, disrupted social networks, lack of collateral informants, and unawareness of local resources complicate treatment. These patients can consume disproportionate time and resources from emergency providers. We review the literature on the emergency psychiatric treatment of peregrinating patients and use case examples to illustrate common presentations and treatment strategies. Difficulties in studying this population and suggestions for future research are discussed.
Increased 30-Day Emergency Department Revisits Among Homeless Patients with Mental Health Conditions
Chun Nuk Lam, MPH, et al.
Patients with mental health conditions frequently use emergency medical services. Many suffer from substance use and homelessness. If they use the emergency department (ED) as their primary source of care, potentially preventable frequent ED revisits and hospital readmissions can worsen an already crowded healthcare system. However, the magnitude to which homelessness affects health service utilization among patients with mental health conditions remains unclear in the medical community. This study assessed the impact of homelessness on 30-day ED revisits and hospital readmissions among patients presenting with mental health conditions in an urban, safety-net hospital.
ED Patients with Prolonged Complaints and Repeat ED Visits Have an Increased Risk of Depression
Kristopher R. Brickman, MD et al.
The objective of this study was to explore associations between presenting chief complaints of prolonged symptomatology, patient usage of the emergency department (ED), and underlying depression so that emergency physicians may better target patients for depression screening.
Volume 17, Issue 3, May 2016
Kenneth D. Katz, MD, et al.
Synthetic cannabinoid use has risen at alarming rates. This case series describes 11 patients exposed to the synthetic cannabinoid, MAB-CHMINACA who presented to an emergency department with life-threatening toxicity including obtundation, severe agitation, seizures and death. All patients required sedatives for agitation, nine required endotracheal intubation, three experienced seizures, and one developed hyperthermia. One developed anoxic brain injury, rhabdomyolysis and died. A significant number were pediatric patients. The mainstay of treatment was aggressive sedation and respiratory support. Synthetic cannabinoids pose a major public health risk. Emergency physicians must be aware of their clinical presentation, diagnosis and treatment.
Volume 17, Issue 3, May 2016
Hyeon-Ju Ryoo, BA et al.
Introduction: Visits to the emergency department (ED) for use of illicit drugs and opioids have increased in the past decade. In the ED, little is known about how gender may play a role in drug-related visits and referrals to treatment. This study performs gender-based comparison analyses of drug-related ED visits nationwide.
Methods: We performed a cross-sectional analysis with data collected from 2004 to 2011 by the Drug Abuse Warning Network (DAWN). All data were coded to capture major drug categories and opioids. We used logistic regression models to find associations between gender and odds of referral to treatment programs. A second set of models were controlled for patient “seeking detox,” or patient explicitly requesting for detox referral.
Results: Of the 27.9 million ED visits related to drug use in the DAWN database, visits by men were 2.69 times more likely to involve illicit drugs than visits by women (95% CI [2.56, 2.80]). Men were more likely than women to be referred to detox programs for any illicit drugs (OR 1.12, 95% CI [1.02–1.22]), for each of the major illicit drugs (e.g., cocaine: OR 1.27, 95% CI [1.15–1.40]), and for prescription opioids (OR 1.30, 95% CI [1.17–1.43]). This significant association prevailed after controlling for “seeking detox.”
Conclusion: Women are less likely to receive referrals to detox programs than men when presenting to the ED regardless of whether they are “seeking detox.” Future research may help determine the cause for this gender-based difference and its significance for healthcare costs and health outcomes.
Volume 17, Issue 3, May 2016
Roland C. Merchant, MD, MPH, ScD
Introduction: Among adult emergency department (ED) patients, we sought to examine how estimates of substance use prevalence and the need for interventions can differ, based on the type of screening and assessment strategies employed.
Methods: We estimated the prevalence of substance use and the need for interventions using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in a secondary analysis of data from two cross-sectional studies using random samples of English- or Spanish-speaking 18–64-year-old ED patients. In addition, the test performance characteristics of three simplified screening strategies consisting of selected questions from the ASSIST (lifetime use, past three-month use, and past three-month frequency of use) to identify patients in need of a possible intervention were compared against using the full ASSIST.
Results: Of 6,432 adult ED patients, the median age was 37 years-old, 56.6% were female, and 61.6% were white. Estimated substance use prevalence among this population differed by how it was measured (lifetime use, past three-month use, past three-month frequency of use, or need for interventions). As compared to using the full ASSIST, the predictive value and accuracy to identify patients in need of any intervention was best for a simplified strategy asking about past three-month substance use. A strategy asking about daily/near-daily use was better in identifying patients needing intensive interventions. However, some patients needing interventions were missed when using these simplified strategies.
Conclusion: Substance use prevalence estimates and identification of ED patients needing interventions differ by screening strategies used. EDs should carefully select strategies to identify patients in need of substance use interventions.
Volume 17, Issue 2, March 2016.
Brian Y. Choi, MD, MPH, et al.
Introduction: A disproportionate number of individuals with human immunodeficiency virus (HIV)
have mental health and substance-use disorders (MHSUDs), and MHSUDs are significantly
associated with their emergency department (ED) visits. With an increasing share of older adults
among HIV patients, this study investigated the associations of MHSUDs with ED outcomes of HIV
patients in four age groups: 21-34, 35-49, 50-64, and 65+ years.
Methods: We used the 2012 Nationwide Emergency Department Sample (NEDS) dataset (unweighted
n=23,244,819 ED events by patients aged 21+, including 115,656 visits by patients with
HIV). Multinomial and binary logistic regression analyses, with “treat-and-release” as the base
outcome, were used to examine associations between ED outcomes and MHSUDs among visits that
included a HIV diagnosis in each age group.
Results: Mood and “other” mental disorders had small effects on ED-to-hospital admissions, as
opposed to treat-and-release, in age groups younger than 65+ years, while suicide attempts had
medium effects (RRR=3.56, CI [2.69-4.70]; RRR=4.44, CI [3.72-5.30]; and RRR=5.64, CI [4.38-
7.26] in the 21-34, 35-49, and 50-64 age groups, respectively). Cognitive disorders had mediumto-large
effects on hospital admissions in all age groups and large effects on death in the 35-49
(RRR=7.29, CI [3.90-13.62]) and 50-64 (RRR=5.38, CI [3.39-8.55]) age groups. Alcohol use
disorders (AUDs) had small effects on hospital admission in all age groups (RRR=2.35, 95% CI
[1.92-2.87]; RRR=2.15, 95% CI [1.95-2.37]; RRR=1.92, 95% CI [1.73-2.12]; and OR=1.93, 95%
CI [1.20-3.10] in the 21-34, 35-49, 50-64, and 65+ age groups, respectively). Drug use disorders
(DUDs) had small-to-medium effects on hospital admission (RRR=4.40, 95% CI [3.87-5.0];
RRR=4.07, 95% CI [3.77-4.40]; RRR=4.17, 95% CI [3.83-4.55]; and OR=2.53, 95% CI [2.70-
3.78] in the 21-34, 35-49, 50-64, and 65+ age groups, respectively). AUDs and DUDs were also
significantly related to the risk of death, and DUDs had a small effect on the risk of discharge
against medical advice in the 35-49 and 50-64 age groups.
Conclusion: The high prevalence of MHSUDs and their significant roles in ED visit outcomes in
patients with HIV provide support for integrated care for these patients outside the ED to reduce
their ED visits and costly hospital admissions and institutional care that follows, especially for the
increasing numbers of older adults with HIV.